Double-Blind Clinical Trials of Oral Triptans Vs Other Classes of Acute Migraine Medication — A Review

Placebo and nocebo in the treatment of migraine: How much does real world effectiveness depend on contextual effects?

PURPOSE

Treatments in medicine impact individuals beyond their intended effects, due to phenomena such as the placebo and nocebo effects. The placebo effect arises from the positive expectation of a treatment being beneficial, while the nocebo effect stems from the negative expectation of a treatment causing harm. Both in real-world practice and clinical trials, treatments can lead to outcomes unrelated to their intended mechanism of action, which we categorize as placebo and nocebo responses. These responses, combined with the inherent fluctuation in a condition's natural progression, regression to the mean, and random comorbidities, make up a significant part of the therapeutic experience. Particularly in pain management, placebo and nocebo effects play a substantial role. By addressing modifiable contextual factors such as patient expectations, lifestyle choices, and the therapeutic relationship, healthcare providers can enhance the effectiveness of migraine treatments, paving the way for a more comprehensive, individualized approach to patient care. We must also consider non-modifiable factors like personal experiences, beliefs, and information from social media and the internet.

CONCLUSION

This review offers a summary of our current understanding of the placebo and nocebo effects in migraine management.

The Role of Step Therapy in the Treatment of Migraine

PURPOSE OF REVIEW

This review examines recent evidence and applies bioethical principles to evaluate the benefits and risks of using step therapy in the treatment of migraine.

RECENT FINDINGS

With the CGRP mAbs, gepants, and lasmiditan now on the market for up to 5 years, new research, including network meta-analyses and long-term use studies, can evaluate the comparative efficacy, tolerability, and adherence of these medications relative to older acute and preventive medications for the treatment of migraine. Deciding how medications are chosen for patients requires accounting for many factors including sustainability, efficacy, tolerability, and preference. Newer research can help give clarity on the appropriateness of gating certain treatment options behind others.

What do patients' efficacy and tolerability ratings of acute migraine medication tell us? Cross-sectional data from the DMKG Headache Registry

BACKGROUND

Most migraine patients need an effective acute medication. Real-world data can provide important information on the performance of acute migraine medication in clinical practice.

METHODS

We used data from the German Migraine and Headache Society Headache Registry, where patients rate efficacy and tolerability of and satisfaction with each of their acute headache medications.

RESULTS

A total of 1756 adult migraine patients (females: 85%, age: 39.5 ± 12.8 years, headache days per month: 13.5 ± 8.1) were included. Of these, 93% used acute medication, most frequently triptans (59.3%) and/or non-opioid analgesics (56.4%), and 58.5% rated efficacy as good or very good. This was more frequent for triptans (75.4%) than for non-opioid analgesics (43.6%, p < 0.001). Among non-opioid analgesics, naproxen was rated most effective (61.9% very good or good, p < 0.001 compared to ibuprofen, acetylsalicylic acid and paracetamol). Patient-rated efficacy significantly declined with higher headache frequencies (p < 0.001), and this effect remained significant after omitting patients overusing acute medication.

CONCLUSION

In the present population recruited at specialized headache centers, patients rated triptans as more effective than non-opioid analgesics, naproxen as more effective than ibuprofen, and acute medication efficacy decreased with increasing headache frequency.Trial registration: The German Migraine and Headache Society Headache Registry is registered with the German Clinical Trials Register (DRKS 00021081).

Comparison of remote electrical neuromodulation (REN) and standard-care medications for acute treatment of migraine in adolescents: a post-hoc analysis

OBJECTIVE

There is an unmet need for new efficacious, well-tolerated, acute treatments for migraine in adolescents. Remote electrical neuromodulation (REN) is a novel, non-pharmacological treatment, that provides significant symptom relief with good tolerability. The current post-hoc analysis compared the efficacy of REN to that of standard-care medications, for the acute treatment of migraine in adolescents.

DESIGN

Within-participant post-hoc analysis of data from a clinical trial.

SETTING

Data from a clinical trial.

SUBJECTS

Data from 35 adolescent participants was analyzed.

METHODS

Efficacy was compared between a run-in phase in which attacks were treated with standard-care medications (triptans or over-the-counter medications), and an intervention phase in which attacks were treated with REN. Efficacy was compared within-participant using McNemar's test, at four endpoints (two hours post-treatment): single-treatment pain freedom and pain relief, and consistency of pain freedom and pain relief (defined as response in at least 50% of the available first four treatments).

RESULTS

At two hours post-treatment, pain freedom was achieved by 37.1% of the participants with REN, vs. 8.6% of the participants with medications (p = 0.004). Pain relief was achieved by 71.4% with REN, vs. 57.1% with medications (p = 0.225). Consistency of pain freedom was achieved by 40% with REN, vs. 8.6% with medications (p < 0.001). Consistency of pain relief was achieved by 80.0% with REN, vs. 57.2% with medications (p = 0.033).

CONCLUSIONS

Our results suggest that REN may have higher efficacy than certain standard-care medications for the acute treatment of migraine in adolescents. A larger scale, blinded, comparative effectiveness and tolerability study is needed.

Targeting the 5-HT system: Potential side effects

Targeting the serotonin (5-HT) system is no simple task: there are at least 15 5-HT receptors, in addition to a number of transporters and metabolizing enzymes. Multiple 5-HT receptor variants exist due to genetic variations and/or post translational modifications, splice variants or editing variants. Some receptors may form homo and heteromers. The 5-HT system is targeted by multiple drugs to treat a variety of diseases. Given the homology amongst the 5-HT and neighbouring receptor classes, only few drugs are actually selective for a single target. In fact, many 5-HT drugs act on a combination of targets, i.e. several receptors and/or transporters or enzymes. For instance, a number of antidepressants or antipsychotics act on 5-HT and other transmitter systems. Recently developed drugs may show target selectivity by design, based on the current state of knowledge, whereas many older compounds hit multiple targets since they were developed using phenotypic screens, as was done well into the 1980's. Ergot analogues, antipsychotics or antidepressants, fall into this category. As our knowledge developed over the last 25-30 years, some targets have very well-defined liabilities: for instance, 5HT_2B or 5-HT_2A receptor agonists, will produce valvulopathies or hallucinations, respectively, whereas 5-HT₃ receptor antagonists, may lead to constipation. This short review will be limited in scope as there are multiple targets and even more compounds to discuss. This article is part of the special issue entitled 'Serotonin Research: Crossing Scales and Boundaries'.

Diagnosis and treatment of migraine: Russian experts' recommendations

Migraine is one of the most common types of headache, which can lead to a significant decrease in quality of life. Researchers identify migraine with aura, migraine without aura, and chronic migraine that substantially reduces the ability of patients to work and is frequently concurrent with mental disorders and drug-induced headache. The complications of migraine include status migrainosus, persistent aura without infarction, migrainous infarction (stroke), and a migraine aura-induced seizure. The diagnosis of migraine is based on complaints, past medical history, objective examination data, and the diagnostic criteria as laid down in the International Classification of Headache Disorders, 3 rd edition. Add-on trials are recommended only in the presence of red flags, such as the symptoms warning about the secondary nature of headache. Migraine treatment is aimed at reducing the frequency and intensity of attacks and the amount of analgesics taken. It includes three main approaches: behavioral therapy, seizure relief therapy, and preventive therapy. Behavioral therapy focuses on lifestyle modification. Nonsteroidal anti-inflammatory drugs, simple and combined analgesics, triptans, and antiemetic drugs for severe nausea or vomiting are recommended for seizure relief. Preventive therapy which includes antidepressants, anticonvulsants, beta-blockers, angiotensin II receptor antagonists, botulinum toxin type A-hemagglutinin complex and monoclonal antibodies to calcitonin gene-related peptide or its receptors, is indicated for frequent or severe migraine attacks and for chronic migraine. Pharmacotherapy is recommended to be combined with non-drug methods that involves cognitive behavioral therapy; progressive muscle relaxation; mindfulness; biofeedback; post-isometric relaxation; acupuncture; therapeutic exercises; greater occipital nerve block; non-invasive high-frequency repetitive transcranial magnetic stimulation; external stimulation of first trigeminal branch; and electrical stimulation of the occipital nerves (neurostimulation).

Utilization of B12 for the treatment of chronic migraine

Chronic migraine is a particular classification of a headache that is typically unilateral and pulsatile and lasts for at least 3 months. Owing to its high prevalence and detrimental impact on personal, social, and economic aspects of patient lives, much desire has gone into fully understanding the pathogenesis of migraine, and to search for therapeutic agents. In addition to current therapeutics such as triptans, ergotamine, and monoclonal antibodies targeting calcitonin gene-related peptide receptors, vitamin B12 has been investigated for its possible use as a prophylactic agent for migraines. Specifically, the observed effects of vitamin B12 on nitric oxide and homocysteine prompt further investigation of its underlying mechanisms in migraine pathophysiology. In this comprehensive review, we provide a brief overview of migraines and current therapies while focusing on the promising role of vitamin B12 as a possible treatment option for chronic migraine management.

Remote electrical neuromodulation (REN) in the acute treatment of migraine: a comparison with usual care and acute migraine medications

Background

There is a significant unmet need for new, effective and well tolerated acute migraine treatments. A recent study has demonstrated that a novel remote electrical neuromodulation (REN) treatment provides superior clinically meaningful pain relief with a low rate of device-related adverse events. The results reported herein compare the efficacy of REN with current standard of care in the acute treatments of migraine.

Methods

We performed a post-hoc analysis on a subgroup of participants with migraine from a randomized, double-blind, parallel-group, sham-controlled, multicenter study on acute care. The original study included a 2–4 weeks run-in phase, in which migraine attacks were treated according to patient preference (i.e., usual care) and reported in an electronic diary; next, participants entered a double-blind treatment phase in which they treated the attacks with an active or sham device. The efficacy of REN was compared to the efficacy of usual care or pharmacological treatments in the run-in phase in a within-subject design that included participants who treated at least one attack with the active REN device and reported pain intensity at 2 h post-treatment.

Results

Of the 252 patients randomized, there were 99 participants available for analysis. At 2 h post-treatment, pain relief was achieved in 66.7% of the participants using REN versus 52.5% participants with usual care (p < 0.05). Pain relief at 2 h in at least one of two attacks was achieved by 84.4% of participants versus 68.9% in usual care (p < 0.05). REN and usual care were similarly effective for pain-free status at 2 h. The results also demonstrate the non-inferiority of REN compared with acute pharmacological treatments and its non-dependency on preventive medication use.

Conclusion

REN is an effective acute treatment for migraine with non-inferior efficacy compared to current acute migraine therapies. Together with a very favorable safety profile, these findings suggest that REN may offer a promising alternative for the acute treatment of migraine and could be considered first line treatment in some patients.

Trial registration

ClinicalTrials.gov NCT03361423. Registered 18 November 2017.

Targeted 5-HT1F Therapies for Migraine

Migraine is a common neurological disease characterised by the presence of attacks of unilateral, severe head pain accompanied by other symptoms. Although it has been classified as the sixth most disabling disorder, the available therapeutic options to treat this condition have not progressed accordingly. The advance in the development of 5-HT1 receptor agonists for migraine, including 5-HT1B/D and 5-HT1F receptor agonists, has meant a major step forward towards the progression of a better treatment for migraine. Triptans have a limited efficacy, and their effect on vasoconstriction makes them unsafe for patients with cardiovascular and/or cerebrovascular diseases. Therefore, novel effective antimigraine treatments without cardiovascular effects are required, such as selective 5-HT1F receptor agonists (ditans). Lasmiditan has much higher affinity for the 5-HT1F receptor than for the vasoconstrictor 5-HT1B receptor. This has been confirmed in preclinical studies performed to date, where lasmiditan showed no effect on vasoconstriction, and in clinical trials, where healthy individuals and patients did not report cardiac events due to treatment with lasmiditan, although it should be confirmed in larger cohorts. Lasmiditan crosses the blood-brain barrier and may act both centrally and peripherally on 5-HT1F receptors expressed on trigeminal neurons. It is a well-tolerated compound that does not induce major adverse events. Although ongoing phase III clinical trials are needed to confirm its efficacy and safety, lasmiditan might offer an alternative to treat acute migraine with no associated cardiovascular risk. This review will focus on the characterisation of 5-HT1 receptor agonists and their effects as migraine therapies.

Migraine Treatment: Current Acute Medications and Their Potential Mechanisms of Action

Migraine is a common and disabling primary headache disorder with a significant socioeconomic burden. The management of migraine is multifaceted and is generally dichotomized into acute and preventive strategies, with several treatment modalities. The aims of acute pharmacological treatment are to rapidly restore function with minimal recurrence, with the avoidance of side effects. The choice of pharmacological treatment is individualized, and is based on the consideration of the characteristics of the migraine attack, the patient's concomitant medical problems, and treatment preferences. Notwithstanding, a good understanding of the pharmacodynamic and pharmacokinetic properties of the various drug options is essential to guide therapy. The current approach and concepts relevant to the acute pharmacological treatment of migraine will be explored in this review.

Post-traumatic headaches

Chronic pain, especially headache, is an exceedingly common complication of traumatic brain injury (TBI). In fact, paradoxically, the milder the TBI, the more likely one is to develop headaches. The environment of injury and the associated comorbidities can have a significant impact on the frequency and severity of headaches and commonly serve to direct management of the headaches. Trauma likely contributes to the development of headaches via alterations in neuronal signaling, inflammation, and musculoskeletal changes. The clinical picture of the patient with post-traumatic headaches is often that of a mixed headache disorder with features of tension-type headaches as well as migrainous headaches. Treatment of these headaches is thus often guided by the predominant characteristics of the headaches and can include pharmacologic and nonpharmacologic strategies. Pharmacologic therapies include both abortive and prophylactic agents with prophylaxis targeting comorbidities, primarily impaired sleep. Nonpharmacologic interventions for post-traumatic headaches include thermal and physical modalities as well as cognitive behavioral approaches. As with many postconcussive symptoms, headaches can lessen with time but in up to 25% of patients, chronic headaches are long-term residua.

Targeted Review: Medications for Acute Migraine Treatment

Objective:

To assess the evidence base for drugs used for acute treatment of episodic migraine (headache on < 14 days a month) in Canada.

Methods:

A detailed search strategy was employed to find relevant published clinical trials of drugs used in Canada for the acute treatment of migraine in adults. Primarily meta-analyses and systematic reviews were included. Where these were not available for a drug or were out of date, individual clinical trial reports were utilized. Only double-blind randomized clinical trials with placebo or active drug controls were included in the analysis. Recommendations and levels of evidence were graded according to the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group, using a consensus group.

Results:

Eighteen acute migraine medications and two adjunctive medications were evaluated. Twelve acute medications received a strong recommendation with supporting high quality evidence for use in acute migraine therapy (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, ASA, ibuprofen, naproxen sodium, diclofenac potassium, and acetaminophen). Four acute medications received a weak recommendation for use with low or moderate quality evidence (dihydroergotamine, ergotamine, codeine-containing combination analgesics, and tramadol-containing combination analgesics). Three of these medications were NOT recommended for routine use (ergotamine, and codeine- and tramadol-containing medications), and strong recommendations were made to avoid use of butorphanol and butalbital-containing medications. Both metoclopramide and domperidone received a strong recommendation for use with acute migraine attack medications where necessary.

Conclusion:

Our targeted review formulated recommendations for the available acute medications for migraine treatment according to the GRADE method. This should be helpful for practitioners who prescribe medications for acute migraine treatment.

Acute Migraine Treatment in Adults

There are many options for acute migraine attack treatment, but none is ideal for all patients. This study aims to review current medical office-based acute migraine therapy in adults and provides readers with an organized approach to this important facet of migraine treatment. A general literature review includes a review of several recent published guidelines. Acetaminophen, 4 nonsteroidal anti-inflammatory drugs (NSAIDs) (ibuprofen, acetylsalicylic acid [ASA], naproxen sodium, and diclofenac potassium), and 7 triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan) have good evidence for efficacy and form the core of acute migraine treatment. NSAID-triptan combinations, dihydroergotamine, non-opioid combination analgesics (acetaminophen, ASA, and caffeine), and several anti-emetics (metoclopramide, domperidone, and prochlorperazine) are additional evidence-based options. Opioid containing combination analgesics may be helpful in specific patients, but should not be used routinely. Clinical features to be considered when choosing an acute migraine medication include usual headache intensity, usual rapidity of pain intensity increase, nausea, vomiting, degree of disability, patient response to previously used medications, history of headache recurrence with previous attacks, and the presence of contraindications to specific acute medications. Available acute medications can be organized into 4 treatment strategies, including a strategy for attacks of mild to moderate severity (strategy one: acetaminophen and/or NSAIDs), a triptan strategy for patients with severe attacks and for attacks not responding to strategy one, a refractory attack strategy, and a strategy for patients with contraindications to vasoconstricting drugs. Acute treatment of migraine attacks during pregnancy, lactation, and for patients with chronic migraine is also discussed. In chronic migraine, it is particularly important that medication overuse is eliminated or avoided. Migraine treatment is complex, and treatment must be individualized and tailored to the patient's clinical features. Clinicians should make full use of available medications and formulations in an organized approach.

Sumatriptan fast-disintegrating/rapid-release tablets in the acute treatment of migraine

Sumatriptan is the first serotonin (5-hydroxytryptamine [5-HT](1B/1D)) receptor agonist specifically designed for the acute treatment of migraine. A new sumatriptan fast disintegrating/rapid release tablet (FDT/RRT) using RT technology has been developed to enhance tablet disintegration and dispersion in the stomach with the intention of speeding absorption and onset of effect, hence mitigating the effects on the gastrointestinal dysmotility that typically accompanies the attack. Sumatriptan FDT/RRT is bioequivalent to conventional tablets, although it provides slightly faster absorption during early post-dose interval. Clinical trials indicate that sumatriptan FDT/RRT is rapidly effective in terms of freedom from pain and return to normal activities, both with early and late treatment. The drug is well tolerated. In an oral formulation, which is the patients' preferred dosing route, sumatriptan FDT/RRT may therefore constitute an advance in the management of acute migraine attacks.

A chronic animal model of migraine, induced by repeated meningeal nociception, characterized by a behavioral and pharmacological approach

BACKGROUND

Migraine is a chronic neurovascular disease characterized by recurrent unilateral headache, which induces incapacity. Despite all the progress that migraine research has provided, the neural mechanisms underlying the onset and maintenance of migraine attacks are poorly understood. Due to the complex characteristics of the disorder, it is difficult to develop a proper animal model that mimics all the clinical manifestations in humans.

OBJECTIVE

Taking into account the principal characteristics of the disease, the aim of this study is to develop a chronic animal model of migraine in which we can reproduce behavioral and pharmacological phenomena similar to those displayed by migraineurs.

RESULTS

Our animal model displayed behavioral and pharmacological results similar to those experienced by migraineurs. Specifically, there was a decrease in routine physical activity and an increase in resting behavior. Also, the animals exhibited a novel behavior that we called ipsilateral facial grooming behavior provoked by the meningeal nociception. Moreover, one of the drugs used as treatment for migraine reduced the manifestations previously described. Our results determine that the model mimics many of the clinical features that patients exhibit during migraine attacks. This model can contribute to further understanding of the pathophysiology and the study of novel therapeutic approaches.

Primary headache disorders and neuro-ophthalmologic manifestations

Headache is an extraordinarily common complaint presenting to medical practitioners in all arenas and specialties, particularly primary care physicians, neurologists, and ophthalmologists. A wide variety of headache disorders may manifest with a myriad of neuro-ophthalmologic symptoms, including orbital pain, disturbances of vision, aura, photophobia, lacrimation, conjunctival injection, ptosis, and other manifestations. The differential diagnosis in these patients is broad and includes both secondary, or symptomatic, and primary headache disorders. Awareness of the headache patterns and associated symptoms of these various disorders is essential to achieve the correct diagnosis. This paper reviews the primary headache disorders that prominently feature neuro-ophthalmologic manifestations, including migraine, the trigeminal autonomic cephalalgias, and hemicrania continua. Migraine variants with prominent neuro-ophthalmologic symptoms including aura without headache, basilar-type migraine, retinal migraine, and ophthalmoplegic migraine are also reviewed. This paper focuses particularly on the symptomatology of these primary headache disorders, but also discusses their epidemiology, clinical features, and treatment.

The influence of multimodal behavioral treatment on the consumption of acute migraine drugs: a randomized, controlled study

OBJECTIVES

To characterize overall drug use in migraine in conjunction with multimodal behavioral treatment (MBT).

METHODS

Seventy-six adults reporting at least two monthly migraine attacks underwent a randomized, controlled, 24-week MBT intervention. Migraine drugs and symptoms were registered in an Internet-based diary.

RESULTS

During 4256 days of baseline registration, 859 drug doses were taken during 655 of the 856 days with migraine headache. Triptans and analgesics constituted 56.7 and 38.3% of all doses with efficacy ratios of 0.41 and 0.20, respectively. Men displayed significantly lower drug efficacy (p = 0.001), and used triptans significantly less (p < 0.001) and analgesics significantly more (p < 0.001) than women. At the end of the MBT, total drug consumption decreased by 22% (p = 0.029), corresponding to 27% fewer days with migraine headache. Drug efficacy increased during MBT from 0.30 to 0.52 (p < 0.001), mainly explained by an increased proportion of mild attacks, which also was the attack category that displayed the largest increase in drug efficacy.

CONCLUSIONS

Triptans were the most used and efficient drugs. MBT led to decreased and more efficient drug consumption. Men used triptans less frequently.

Headaches due to external compression

Headache is one of the most common types of recurrent pain in medical practice. Although nearly everyone has occasional headaches, there are well-defined headache disorders that vary in incidence and prevalence. Among the unusual headache syndromes, headache due to external compression is a poorly studied headache considered to arise as a result of continued stimulation of cutaneous nerves by the application of pressure over the scalp or forehead. The wearing of bands around the head, specifically goggles (such as those worn for swimming), tight hats, or even professional helmets have been described as causative factors. The pain is often constant and more severe at the location where the object is pressing the head. In predisposed patients (ie, those with migraine), external compression may lead to a more severe migrainous headache if the stimulus is prolonged. The mechanism responsible is the compression of trigeminal or occipital nerves branches. The headache resolves after pressure is relieved, or is prevented by avoiding the precipitating cause. Drugs are rarely used.

Migraine surgery: a plastic surgery solution for refractory migraine headache

Migraine headache can be a debilitating condition that confers a substantial burden to the affected individual and to society. Despite significant advancements in the medical management of this challenging disorder, clinical data have revealed a proportion of patients who do not adequately respond to pharmacologic intervention and remain symptomatic. Recent insights into the pathogenesis of migraine headache argue against a central vasogenic cause and substantiate a peripheral mechanism involving compressed craniofacial nerves that contribute to the generation of migraine headache. Botulinum toxin injection is a relatively new treatment approach with demonstrated efficacy and supports a peripheral mechanism. Patients who fail optimal medical management and experience amelioration of headache pain after injection at specific anatomical locations can be considered for subsequent surgery to decompress the entrapped peripheral nerves. Migraine surgery is an exciting prospect for appropriately selected patients suffering from migraine headache and will continue to be a burgeoning field that is replete with investigative opportunities.

Efficacy and tolerability of a new powdered formulation of diclofenac potassium for oral solution for the acute treatment of migraine: results from the International Migraine Pain Assessment Clinical Trial (IMPACT)

OBJECTIVE

This study assessed the efficacy of diclofenac potassium for oral solution, a novel water-soluble buffered powder formulation, versus placebo for the acute treatment of migraine. Diclofenac potassium for oral solution has a time to maximum plasma concentration (Tmax) of 15 minutes, suggesting the potential for a rapid onset of therapeutic effects.

METHODS

This was a randomized, double-blind, parallel-group, placebo-controlled study conducted in 23 US centers. Adult sufferers with an established migraine diagnosis according to the International Classification of Headache Disorders, second edition (ICHD-II), treated one moderate or severe attack with 50 mg diclofenac potassium for oral solution (dissolved in approximately 2 ounces of water; N=343) or matching placebo (N=347). Four co-primary endpoints included the percentage of subjects who at two hours post-treatment reported no headache pain, no nausea, no photophobia and/or no phonophobia.

RESULTS

Significantly more subjects treated with diclofenac potassium for oral solution (N=343) achieved a two-hour pain-free response (25% vs. 10%, p<.001), no nausea (65% vs. 53%; p=.002), no photophobia (41% vs. 27%; p<.001) and no phonophobia (44% vs. 27%; p<.001) compared to placebo. Pain intensity differences between treatments were significantly lower in the diclofenac potassium oral solution group, starting at 30 minutes post-treatment (p=.013) with significant differences at all time points thereafter (p<.001). Twenty-four-hour sustained pain-free response favored diclofenac potassium oral solution treatment versus placebo (19% vs. 7%, p<.0001). The most common adverse event considered to be treatment related was nausea (diclofenac potassium for oral solution [4.6%]; placebo [4.3%]).

CONCLUSIONS

This study shows that this formulation of diclofenac potassium for oral solution is effective in reducing pain intensity within 30 minutes, which may be related to the 15-minute T(max) associated with this formulation. The rapid-onset benefits were sustained through 24 hours post-treatment.

Triptans: low utilization and high turnover in the general population

Studies performed in selected populations have shown a poor utilization of triptans for migraine. Our study was aimed at establishing patterns of triptans utilization in a large community using the pharmaceutical prescriptions database of two consecutive years in a regional Health Authority in Italy. About 0.5% of the population observed received triptans prescriptions in a year, but > 50% of the cases received only one prescription. On the other hand, 46% of triptan users did not receive a triptan prescription in the following year (past users): in 80% of cases, patients received only 1-2 triptan packages. The evaluation of the discontinued triptan type has shown percentages varying between 30 and 70%. The percentage of triptan users who received a triptan prescription for the first time in the successive year of study (new users) was 52%. These findings together highlight a high turnover in triptans utilization. Less than 15% of subjects received more than one triptan product in the 2 years. In conclusion, we observed a low percentage of triptan users and a low rate of utilization, associated with a high percentage of discontinuation and new utilization (high turnover), without any substantial increase in triptans utilization during the years. All these data probably do not support optimal satisfaction with triptan therapy.

Acute migraine treatment with oral triptans and NSAIDs in a managed care population

OBJECTIVE

To describe the use of oral triptans with or without nonsteroidal anti-inflammatory drugs (NSAIDs) for acute migraine treatment in a managed care population and its potential impact on functionality.

BACKGROUND

Prescription or over-the-counter NSAIDs with or without oral triptans are commonly used for treatment of acute migraine pain. Little is known about patients' treatment strategy when they have had experiences using NSAIDs and oral triptan cotherapy and the relationship between treatment strategy and migraine symptoms and functionality.

METHOD

Migraineurs identified from an administrative claims database were surveyed for their use of oral triptans and NSAIDs during their last attack in the screening phase and during the subsequent migraine attack in the follow-up phase of the study. Treatment regimens were classified into 6 categories: simultaneous coadministration of triptans and NSAIDs (T and N); triptans first followed by NSAIDs (T N); NSAIDs first followed by triptans (N T); triptans only (TRP only); NSAIDs only (NSAID only); and others. Headache experience, reasons for treatment regimens, and treatment satisfaction were cross-tabulated by treatment regimens. The log-rank test was used for the analysis of time-to-event data.

RESULTS

Among 8440 oral triptan users surveyed during the screening phase, 2307 (27%) reported using triptans and NSAIDs combination therapy during their last migraine attack. Of those, 1502 experienced a subsequent migraine attack and completed the follow-up survey; 38% of these 1502 patients who used triptans and NSAIDs cotherapy during their last migraine attack continued to use combination therapy for their next attack. The most common treatment regimen, excluding "others" (n = 354, 24%), was TRP only (n = 403, 27%), followed by N T (n = 345, 23%), NSAID only (n = 170, 11%), T&N (n = 152, 10%), and T N (n = 75, 5.0%). More TRP only patients became nausea-free within 1 h after an initial dosing. TRP only, T&N, and N T had significantly shorter median hours of suffering from migraine and limited functioning, as compared with other treatment regimens. Substantially more patients taking TRP only (34.7%) were very satisfied with their current treatment regimen than other regimens.

CONCLUSIONS

Migraine patients frequently change their treatment regimens in response to headache profiles. For patients with migraine associated nausea symptom, combination of therapy with triptan and NSAIDs appears to be less effective in relieving nausea than triptan monotherapy. Triptan montherapy remains a common and an effective migraine treatment strategy.

Triptans vs other drugs for acute migraine. Are there differences in efficacy? A comment

The introduction of triptans in migraine treatment was apparently a revolution. Comparative randomized clinical trials (RCTs) with triptan and other drugs do not give a clear-cut picture. Oral triptans are superior to oral ergotamine most likely because the bioavailability oral of ergotamine is extremely low (<1%). Compared with NSAIDs, in most cases aspirin, triptans were not superior and in several RCTs triptans caused more adverse events than aspirin plus metoclopramide. Guidelines for treatment of migraine should be evidence-based. It is suggested that based on current evidence, effervescent aspirin should be the first-line drug for the treatment of migraine. Aspirin is also much cheaper than the triptans.

Combining proof-of-concept with dose-finding: utilization of adaptive designs in migraine clinical trials

There is an obvious need to improve clinical trial designs with respect to efficiency, duration and the number of patients recruited. Adaptive (flexible) designs may be valuable in this respect. We simulated the properties of a two-stage adaptive proof-of-concept and dose-finding trial design in adult migraine patients with moderate to severe headache, with or without aura. We also assessed the usefulness of a combined Bayesian and frequentist approach in the estimation of the probability of success of subsequent Phase III studies. Applying such an innovative approach would result in a reduction of the required sample size by 30 patients and no prolongation of the trial duration. The probability of success in Phase III is > 81%. An innovative adaptive design can facilitate testing of investigational migraine medications by reducing patient numbers and improving predictivity of success in Phase III.

Pharmacogenomics and migraine: possible implications

Pharmacogenomics is the science about how inherited factors influence the effects of drugs. Drug response is always a result of mutually interacting genes with important modifications from environmental and constitutional factors. Based on the genetic variability of pharmacokinetic and in some cases pharmacodynamic variability we mention possible implications for the acute and preventive treatment of migraine. Pharmacogenomics will most likely in the future be one part of our therapeutic armamentarium and will provide a stronger scientific basis for optimizing drug therapy on the basis of each patient’s genetic constitution.

Over-the-counter triptans for migraine : what are the implications?

In 2006, the triptans sumatriptan 50mg and naratriptan 2.5mg were approved as over-the-counter (OTC) drugs in pharmacies in the UK and Germany, respectively. Both drugs have been used in a large number of patients with migraine and are considered to have good safety profiles. The implications of OTC triptan availability for clinical practice are that more migraine patients will use a triptan and will tend to medicate early when their headache is still mild, which should be beneficial. The problem with OTC access to triptans is medication overuse; therefore, patients should be warned of this and advised to use a triptan on fewer than 10 days per month. Pharmacists should be educated regarding migraine types and symptoms and on contraindications to triptans, so they are then able to discern the patients who should receive triptans and, as importantly, those who should not. The annual cost of migraine is euro27 billion in Europe, $US1.4 billion in the UK and $US16.6 billion in the US. By far the greatest opportunity for cost-savings comes from the potential to reduce costs associated with lost productivity from migraine. OTC availability of triptans will inevitably result in easier access to these medications, which, in turn, may result in improved treatment and lower migraine-related disability. There is currently a lack of empirical evidence that treating migraine effectively does in fact recover lost productivity; well designed studies are required to show this. The availability of triptans OTC is a logical development for the better management of a common, benign, self-limiting but nonetheless burdensome disorder that is currently grossly undertreated. We welcome this development, but recognise that advice at the point of sale is crucial for effective and safe use of these drugs.

Patterns of triptans use: a study based on the records of a community pharmaceutical department

Studies performed in selected populations show that the use of triptans for migraine is low. Our study was aimed at establishing patterns of triptan utilization in a large community using the drug prescription database of a regional Health Authority in Italy. In a population of 224,065 residents, 0.55% received at least one prescription of triptans in 1 year: 77.9% were female and 22.1% male. Oral dosage forms accounted for 94% of prescriptions. About 60% of patients received a single prescription (containing one or two packages) of one triptan in 1 year. Age distribution showed that 7% of patients were aged > 65 years. They received 14% of packages, prevalently sumatriptan and zolmitriptan (the two triptans with the longest commercialization in Italy); 5.7% of patients received 40% of packages. Moreover, 3.2% of triptans users received > 120 dosage units in the year in the form of tablets (>10 single doses/month), and were potential triptan abusers. Our data indicate suboptimal treatment of migraine patients and also incorrect treatment of some patients (potential triptans abusers, the elderly).

Efficacy and safety of 1,000mg effervescent aspirin: individual patient data meta-analysis of three trials in migraine headache and migraine accompanying symptoms

Migraine is often associated with health consequences including impaired quality of life, and the cost of treating migraine headaches places a significant financial burden on patients who suffer from migraines. Nonsteroidal anti-inflammatory drugs (NSAIDs) and triptans are commonly used for the treatment of acute migraine attacks. Aspirin is widely accepted as a treatment option for migraine pain relief and could provide an alternative not only for treatment of moderate migraine attacks, but also for severe migraine attacks. The efficacy and safety of 1,000 mg effervescent aspirin (eASA) was evaluated in comparison to 50 mg sumatriptan and placebo in an individual patient data meta-analysis of three randomized, placebo-controlled, single- dose migraine trials. Pain-relief at 2 h, pain-free at 2 h and sustained pain-free up to 24 h were calculated. For eASA, the response rates were 51.5 % (95 % CI: 46.6-56.5 %), 27.1 % (95 % CI: 22.6-31.4 %), and 23.5 % (95 % CI: 19.3-27.7 %). For sumatriptan, the response rates were 46.6 % (95% CI: 40.0-53.2 %), 29% (95 % CI: 23.0-34.9 %), and 22.2 % (95 % CI: 16.7-27.6 %). The corresponding rates for placebo were 33.9 % (95% CI: 29.1-38.6 %), 15.1 % (95 % CI: 11.5-18.7 %), and 14.6 % (95 % CI: 11.0-18.1 %). The treatment effect of eASA and sumatriptan were significantly different from placebo (p < 0.001), but differences between eASA and sumatriptan were not significant. The remission of accompanying symptoms and the subgroup analyses of patients with moderate or severe migraine pain at baseline revealed no significant differences between eASA and sumatriptan. Safety was evaluated based on the frequency of reported adverse events, and treatment with eASA was associated with lower incidence of adverse events than was with sumatriptan. This individual patient data meta-analysis provided evidence that eASA 1,000 mg is as effective as sumatriptan 50mg for the treatment of acute migraine attacks and has a better side effect profile. This is also true for patients with moderate as well as severe headache at baseline. Patients therefore should be advised to use eASA first for migraine attacks and use a triptan in case of no response.

Medication use in a female orofacial pain population

OBJECTIVE

This study compared, both quantitatively and qualitatively, the self-reported medication usage between an adult female orofacial pain population and a comparison group.

STUDY DESIGN

Eighty-seven subjects from both an orofacial pain center (OPC) and undergraduate dental clinic (UDC) completed a standardized medical history questionnaire. Both groups had a similar distribution with regard to age. The number of medications and medication categories were compared between the two groups. Statistical analysis used the Student t-test, Fisher's exact tests, Pearson's chi2 tests, and calculated odds ratios.

RESULTS

The number of pain and non-pain medications, and the number of medication categories endorsed by OPC subjects was significantly higher compared with the UDC group.

CONCLUSION

Adult female orofacial pain subjects report greater overall and higher rate of medication use, which was not limited to only the analgesic/narcotic categories, than the comparison group.

Triptans--why once?

OBJECTIVE

To evaluate triptan use patterns in a large Israeli HMO district.

BACKGROUND

Triptans, 5HT(1B/1D) agonists, provide an effective and safe relief of headache and accompanying symptoms during an acute migraine attack.

METHOD

We retrospectively reviewed the computerized prescription filling data of 1498 patients who filled a first triptan prescription between July 2003 and June 2004.

RESULTS

During a 1-year follow-up period, 841 patients (56.1%) purchased triptans only once. Single-time users were significantly more prevalent among men and in patients younger than 30 or older than 70 years.

CONCLUSIONS

It seems that many migraine patients choose not to use triptans after their first experience with the drug.

Acute migraine treatment: patterns of use and satisfaction in a clinical population

BACKGROUND

The sequence and timing of taking migraine medications, whether prescription or over-the-counter, and the patient's response to their treatment, is unknown.

OBJECTIVE

To describe the use of, response to, and satisfaction with acute medications for 1 migraine attack.

METHODS

We performed a clinic-based survey of 127 patients at Jefferson Headache Center, Philadelphia. Adult patients who met the International Headache Society criteria for migraine with or without aura were included in the study. Patients were asked to complete a questionnaire.

RESULTS

Of 109 participants who met the inclusion criteria, most waited 1 hour or more after the onset of symptoms to take medication. Triptans were most commonly used as first, second, and third medications. Triptan use was associated with higher 2-hour pain-free response rates compared with other agents, whether the triptan was used as the first, second, or third medication. Patients who were treated with medications other than triptans were more likely to have pain at 2 hours (P = .36). NSAIDs had relatively low pain-free and headache relief response rates at 2 hours. Sixty-two participants (56.9%) had to treat a second time and 31 (28.4%) had to treat a third time. Some participants (17.6%) had headache recurrence within 24 hours after becoming headache free following initial medication and some (23.5%) had recurrence after becoming headache free following their second medication. Sixty-six percent of participants reported being very satisfied/satisfied with their initial medication and 33% were somewhat dissatisfied/dissatisfied to some degree. Even though most patients were satisfied with their medication, 88% reported that they would be willing to try a new antimigraine medication. Most patients (60 [55%]) preferred a long-acting agent versus a rapid-onset, short-acting agent (which was preferred by 49 [45%] patients).

CONCLUSION

Migraine patients have treatment preferences. They generally want a drug that provides complete headache relief, and they are often satisfied with the current treatment options.

Modes de prescription et de consommation des triptans en Alsace : un mésusage fréquent mais évitable

AIMS

To analyze use of triptans in the Alsace region of France: patients, disorders motivating, doses, analgesics and migraine prophylactics associated treatments, contra-indications. To study major consumers (more than 144 intakes per year) and to determine among them the proportion who suffering from chronic headache.

METHOD

Data concerning all prescriptions of triptans and analgesics as well as migraine prophylaxis prescriptions were obtained from the computer databases of five of the French National Health's local health agencies in Alsace, recorded between April 1, 2003 and March 31, 2004. Data about motivating disorders and the clinical context were obtained using a questionnaire sent to prescribers. Data about patients with more than 144 intakes per year were provided by medical advisors of French Health insurance.

RESULTS

We founded 20686 users: 92.1 percent used between 0 and 6 intakes per month. 11.5 percent of disorders motivating the prescription that were mentioned by prescribers were for off-label use: tension-type headache 2.7 percent, mixed headache, 8.8 percent. Prescribers declared at least one contra-indication for triptan use for 7.8 percent of patients. Over all, prescriptions were off-label for 16.1 percent of patients. Patients who used more than 144 intakes per year accounted for 1.9 percent of the total number and self-medication accounted for 19.2 percent of all triptan intakes. Half of the patients were suffering from daily chronic headache (chronic migraine in 66 percent). 15.6 percent of these patients presented at least one contraindication (high blood pressure or ischemic disease). All in all we estimate that use of triptan is a misuse for 25 percent to 30 percent of the intakes. Quantities of other analgesics used increased simultaneously with triptan use: on average 65, 119 and 244 Defined Daily Doses (DDD)/person/year for patients who used between 1 and 72, 73 and 144 and more than 144 intakes respectively. On average 35.4 percent (in DDD) of analgesics used were opiates (dextropropoxyphene, codeine, tramadol). This proportion increased simultaneously with triptan use: 58.9 percent for major users. Prophylactic treatment for migraine was used by 27.9 percent of the patients: lack of prophylaxis was a prescriber's choice in 90 percent of the cases.

CONCLUSIONS

The high rate of triptan misuse emphasizes the importance of improving prescription of these drugs.

Efficacy and Tolerability of Almotriptan in Postmarketing Surveillance Studies

While randomized, double-blind, placebo-controlled trials are considered the gold standard of clinical evidence, they are limited by patient numbers, duration of patient exposure, and restricted patient populations. Data from controlled trials may not be generalizable to all individuals likely to take the drug under investigation. Postmarketing surveillance studies are designed to measure efficacy and safety in larger and more diverse populations, allowing them to detect less common and delayed adverse events. However, postmarketing surveillance studies are limited by their lack of randomization, open-label design that can result in patient and physician bias, incomplete follow-up, less than rigorous outcome measurement, and lack of a contemporaneous control group. With regard to acute treatment of migraine, clinical trials using per protocol primary endpoints do not reflect the more favorable experience with triptans in general practice. Postmarketing surveillance studies have been performed to determine whether the high levels of efficacy and tolerability of almotriptan reported in controlled clinical trials can been reproduced in routine practice. An observational study conducted in Spain with 2,074 migraine sufferers (4,183 attacks) reported a 2-hour pain-relief rate of 86.9%, a 2-hour pain-free rate of 51.5%, and a sustained pain-free rate of 46.0%; 1.1% of patients reported adverse reactions. A German postmarketing study in 899 patients (2,131 attacks) with acute migraine treated with almotriptan 12.5 mg reported 2-hour pain relief in 84.5% of attacks and 2-hour pain free in 41.4%; 1.1% of patients reported adverse reactions. The consistency of response (at least two out of three attacks successfully treated) with almotriptan 12.5 mg was 87.3%. Regarding satisfaction, 88.5% of patients were satisfied or very satisfied and 80.3% of patients stated that almotriptan was better compared to their prior therapy; 92% of physicians indicated that they would continue treating their patients' migraines with almotriptan. The results of these studies demonstrate that the high levels of efficacy and tolerability seen with almotriptan in controlled clinical trials are achieved in real-world clinical settings. In conclusion, a combination of controlled clinical trials, postmarketing surveillance studies, and physician's experience in the general population can give us a better understanding of the efficacy and tolerability of acute migraine agents.

Migraine Treatment With Rizatriptan and Non‐Triptan Usual Care Medications: A Pharmacy‐Based Study

OBJECTIVE

To compare the effectiveness of rizatriptan to other non-triptan medications in the relief of migraine headache in usual care settings.

BACKGROUND

Although rizatriptan has been shown to provide effective relief of migraine symptoms in clinical trials, limited data exist directly comparing its effectiveness with non-triptan medications.

METHODS

Migraineurs aged 18 to 55 who had been prescribed a new antimigraine drug (rizatriptan 10 mg or a selected class of non-triptan oral medications) were recruited to participate in the study through a national retail pharmacy chain. Participants completed a baseline questionnaire at the enrollment and reported their treatment experiences by filling out the treatment diary after using the newly prescribed medication. The treatment outcomes of patients receiving rizatriptan were compared with those receiving non-triptan medications. Logistic regression analysis was applied to test statistical significance with adjustment for potential confounding factors.

RESULTS

Of the 728 patients who entered the study, 693 (95.2%) completed the treatment diary. Patients treated with rizatriptan (192) and non-triptans (501) reported the following outcomes, respectively--onset of headache relief within 30 minutes post-dose: 25% versus 18%; self-defined significant headache relief within 2 hours post-dose: 71% versus 54%; pain free or mild pain at 2 hours post-dose: 58% versus 47%; completely symptom-free within 2 hours of post-dose: 32% versus 20%; return to usual activities within 2 hours post-dose: 39% versus 35%; and satisfied with treatment: 67% versus 55% (P <.05 in all comparisons with exception of returning to usual activities).

CONCLUSION

Rizatriptan was significantly more effective than non-triptans in the relief of migraine headaches for patients obtaining prescribed migraine medications from a retail pharmacy. Additional studies at other usual care settings may be needed to confirm the findings.